Physical Therapist License Protection Case Study: Falsified Documentation of Treatment Sessions

Summary

The insured physical therapist (PT) was employed by a home healthcare physical therapy practice for approximately one year at the time of the incident.  Though the providers, including the PT, were to input their treatment notes and documentation into the practice’s electronic system, the practice also had patients sign and initial paper forms at the time of treatment sessions.

During the first six months of employment, the PT’s supervisor was conducting an audit of the practice’s records. In reviewing the records, the supervisor realized that a patient’s initials and signatures for two recent visits with the insured PT did not match. Upon questioning the PT, he denied falsifying a visit, but admitted to accidentally signing the patient’s initials on the documentation. The PT was given a verbal warning not to repeat that behavior, and the supervisor explained to the PT that this action was considered fraud, which the PT understood.

Approximately six months later, a caregiver for a different patient called the practice to inquire when the patient’s next physical therapy visit would occur. The caregiver was told by the practice that both weekly visits had been documented. However, the caregiver stated that only one visit had taken place.

Based on the initial issue with the PT’s documentation, the practice reviewed the records of several other patients, phoning each of these patients to inquire about the number of times they had seen the PT in recent weeks. It was determined that the PT had falsified visits for two other patients. When confronted with this additional information, the PT admitted that he falsified the records for all three patients. The PT stated that he entered the session as a “placeholder” early in the day and had intended to treat the patients later that day but did not get a chance to go see the patient and never corrected his documentation. Based on this additional information, the PT was terminated from his position at the practice. The PT’s supervisor filed a complaint with the SBPT, which opened an investigation into the PT’s conduct.
 

The Board’s Investigation

According to SBPT interviews with the PT, he first explained to the Board that he had been told by a preceptor that this was an acceptable practice. When the Board asked him to provide the name and contact information for this person, he could not produce it. Next, he explained to the Board that it was his “first time hearing of” this type of scenario as an example of fraudulent documentation. However, the supervisor gave testimony that disputed this by letting the Board know of the results of the audit and the discussion with the PT that was had at that time. Lastly, the PT stated that he was going through some personal issues and falsified the patients’ records because he thought this was a “victimless crime.” In the end, he admitted to needing extra money for recent medical treatment. During this portion of the Board interview, the PT became agitated. He began to respond angrily to the interviewer’s questions, mumbled under his breath, stopped making eye contact with Board staff, and indicated that he wanted to end the interview and leave. After the interview, the Board opined that the PT’s behavior during the interview caused the Board to become concerned regarding his ability to treat patients safely and referred him for a psychological evaluation. The Board sent the PT a letter by certified and regular mail to his address of record, directing him to contact a Board-appointed evaluator to undergo the evaluation. Three months later, the evaluator notified the Board that the PT had not contacted their office. The PT did not respond to further Board attempts to contact him.
 

Resolution

The SBPT opined that proper documentation ensures that a patient’s records fully and accurately detail the patient’s treatment history, to indicate what interventions have been and have not been effective, to allow future physical therapists and other health care professionals to know the type and extent of treatments that have been attempted, and to allow insurance companies or other third-party payers to cover treatment as necessary. Falsifying treatment records is not a “victimless” transgression – inaccurate treatment records can impact a patient’s current and future treatment and can cause insurance and financial trouble for a patient.

The  repeated allegations of fraud against the PT were difficult to defend, especially considering that the PT admitted that he falsified treatment records for his own financial gain, without regard to the effects such false records could have on his patients. Such decision-making led the Board to question the PT’s professionalism and raised significant concerns about his ability to make ethical decisions in the future.

Although the SBPT takes the falsification of treatment records seriously, they also understand that mistakes can happen.  PTs can learn from documentation mistakes to become better practitioners. To takes steps toward improvement, PTs need to be able to admit wrongdoing. If a licensee becomes confrontational with Board staff, fails to cooperate with the Board’s investigation, refuses to submit to an evaluation, and terminates contact with the Board, the Board cannot ensure that the PT will conduct themselves properly with patients in the future and in accordance with the rules and regulations of the profession.

The Board could not in good conscience allow the PT to continue practicing physical therapy and revoked the PTs license.

Total incurred: More than $9,700.

(Note: Monetary amounts represent solely the legal defense expenses paid on behalf of the insured PT.)
 

Risk Control Recommendations for Physical Therapists

Below are some proactive strategies to include in your practice to help mitigate the risk of SBPT complaints:
 
Document your patient care assessments, observations, communications and actions in an objective, timely, accurate, complete, and appropriate manner. Documentation should support the treatment plan and also satisfy SBPT, regulatory and third-party billing requirements. When more than one requirement applies, adhere to the most stringent policy.

Never ignore a request from the Board. You may receive a letter, email or a phone call from the SBPT asking you to submit a written statement explaining the reported incident. Or the SBPT may require you to appear at a certain time and date for an interview with the investigator. Promptly contact and return calls from your defense attorney and professionals managing your matter.  

If you are contacted by the SBPT, consult with an attorney before you respond, being sure to reply within the deadline set by the Board. You must be cooperative, but be aware that whatever information you share is evidence the investigator will provide to a prosecuting attorney or the SBPT.

Physical therapy professionals should not appear at SBPT proceedings without legal counsel present. Look to your legal counsel for guidance before answering questions from or making statements to the SBPT or the investigator. Your attorney may be able to speak to the investigator, learn more about your matter, and help you navigate the entire process.

Maintain files that can be helpful to your character. Retain copies of letters of recommendation, performance evaluations, thank-you letters from patients, awards, records of volunteer work and continuing education certificates.

_{The information, examples and suggestions presented in this material have been developed from sources believed to be reliable, but they should not be construed as legal or other professional advice. CNA accepts no responsibility for the accuracy or completeness of this material and recommends the consultation with competent legal counsel and/or other professional advisors before applying this material in any particular factual situations. This material is for illustrative purposes and is not intended to constitute a contract. Please remember that only the relevant insurance policy can provide the actual terms, coverages, amounts, conditions and exclusions for an insured. All products and services may not be available in all states and may be subject to change without notice.  Certain coverages may be provided by a surplus lines insurer. Surplus lines insurers do not generally participate in state guaranty funds, and insureds are therefore not protected by such funds.  The claims examples are hypothetical situations based on actual matters.  Settlement amounts are approximations. Certain facts and identifying characteristics were changed to protect confidentiality and privacy. “CNA” is a registered trademark of CNA Financial Corporation. Certain CNA Financial Corporation subsidiaries use the “CNA” trademark in connection with insurance underwriting and claims activities.  This material is not for further distribution without the express consent of CNA. Copyright © 2025 CNA. All rights reserved.}